2013 Preventive/Comprehensive

Dental HMO Overview

The Health Net HMO Dental Plan provides
convenient coverage for preventive, basic and
major dental care and diagnostic services. All
these dental services are coordinated by your
primary care general dentist. There’s no charge
for preventive care, and additional services are
provided at varying copayments.
The following information explains the dental benefits available
as a core benefit for the Health Net Jade (HMO SNP), Health Net
Seniority Plus Ruby (HMO), and Health Net Gold Select (HMO)
plans, or if you purchase the Optional Supplemental Benefits Package
Plan #1 or Package Plan #3 that may be available at an additional
monthly premium with these Health Net Medicare Advantage HMO plans:
Health Net Seniority Plus Green (HMO), Health Net Ruby Select (HMO),
Health Net Seniority Plus Ruby (HMO), Health Net Seniority Plus Ruby
Plan 1 (HMO), Health Net Seniority Plus Ruby Plan 2 (HMO), Health Net
Healthy Heart (HMO), Health Net Healthy Heart Plan 1 (HMO), Health Net
Healthy Heart Plan 2 (HMO).

In order to receive dental benefits, you must select a Health Net participating
dental provider. Choose a Health Net participating dentist from the Health Net
Dental Plan Provider Directory and complete the Health Net Dental Provider
Selection form. The directory lists providers participating in the Health Net
Dental HMO program.

Material ID # H0562_2013_0047 CMS Accepted 08042012

Listed below are some common procedures and copayments:
Procedure Procedure Member Frequency
code description copayment limitation
Diagnostic – Examinations and X-Rays
D0120 Periodic oral evaluation – No charge N/A
established patient
D0150 Comprehensive oral evaluation – No charge N/A
new or established patient
D0210 Intraoral – complete series No charge N/A
(including bitewings)
Preventive – Cleaning and fluoride
D1110 Prophylaxis – adult No charge 2 per calendar
year
D1204 Topical application of fluoride – No charge N/A
adult
Restorative – Fillings and crowns
D2140 Amalgam – one surface (primary) $10 N/A
D2330 Resin-based composite – $20 N/A
one surface, anterior
D2390 Resin-based composite crown, $50 N/A
anterior (primary)
D2391 Resin-based composite – $45 N/A
one surface, posterior (primary)
D2751 Crown – porcelain fused to $225 N/A
predominantly base metal
D2752 Crown – porcelain fused to noble $ 2251 N/A
metal
D2791 Crown – full cast predominantly $225 N/A
base metal
D2792 Crown – full cast noble metal $2251 N/A
Endodontics
D3320 Endodontic therapy, Bicuspid I $145 N/A
(excluding final restoration)
D3330 Endodontic therapy, molar $225 N/A
(excluding final restoration)
Periodontics
D4341 Periodontal scaling and root $40 N/A
planing – four or more teeth per
quadrant
D4342 Periodontal scaling and root $40 N/A
planing – one to three teeth per
quadrant
D4355 Full mouth debridement to enable $40 N/A
comprehensive evaluation and
diagnosis

1Dentalcopayments have an additional charge not to exceed the actual lab cost
for precious and semiprecious metals.
Procedure Procedure Member Frequency
code description copayment limitation
Periodontics (cont.)
D4910 Periodontal maintenance $35 N/A
Oral surgery – Extractions
D7111 Extraction, coronal remnants – $15 N/A
deciduous tooth
D7140 Extraction, erupted tooth or $15 N/A
exposed root (elevation and/or
forceps removal)
D7210 Surgical removal of erupted $40 N/A
tooth requiring elevation of
mucoperiosteal flap and removal
of bone and/or section of tooth
Bridges
D6211 Pontic – cast predominantly $225 N/A
base metal
Dentures
D5110 Complete denture – maxillary $200 N/A
D5120 Complete denture – mandibular $200 N/A
D5211 Maxillary partial denture – resin $200 N/A
base (including any conventional
clasps, rests and teeth)
D5212 Mandibular partial denture – resin $225 N/A
base (including any conventional
clasps, rests and teeth)
Orthodontics and general services
D8090 Comprehensive orthodontic $2,250 N/A
treatment of the adult dentition
D9110 Palliative (emergency) treatment of $20 N/A
dental pain – minor procedure
D9210 Local anesthesia not in No charge N/A
conjunction with operative or
surgical procedures
D9220 Deep sedation/general anesthesia $125 N/A
– first 30 minutes
D9221 Deep sedation/general anesthesia – $60 N/A
each additional 15 minutes
In addition to the exclusions and limitations listed above, dental care benefits are
subject to the plan’s general exclusions and limitations. Additional services are
provided at varying copayments. Please refer to your Evidence of Coverage for
the complete schedule of copayments.
Liability for payment
You are responsible for paying for any services you receive from a dentist not
affiliated with the Health Net Dental Plan. You also will be charged for any
services you receive that exceed the benefits covered under this plan.

How to enroll in the Health Net Dental Plan

• Choose a Health Net participating dentist from the Health Net Dental Plan
Provider Directory.
• Fill in the dental number of your primary care general dentist on the
Health Net Dental Provider Selection form.
• Mail the completed Health Net Dental Provider Selection form to the
following address:
Health Net Dental
PO Box 25187
Santa Ana, CA 92799-5187
That’s all you need to do to enroll! If you have any questions, please contact us at:
Prospective members should call 1-800-977-6738 (TTY/TDD 1-800-929-9955),
8:00 a.m. to 8:00 p.m. Pacific time, seven days a week.
Interpreter services are available by calling our Customer Contact Center:
1-800-977-6738 (TTY/TDD 1-800-929-9955), 8:00 a.m. to 8:00 p.m.
Pacific time, seven days a week.
Health Net of California, Inc. is a Medicare Advantage organization with a
Medicare contract. Health Net of California, Inc. is a Coordinated Care plan
with a Medicare contract.
The benefit information provided is a brief summary, not a complete
description of benefits. For more information, contact the plan. Limitations,
copayments, and restrictions may apply. Benefits, formulary, pharmacy
network, premium and/or copayments/coinsurance may change on January 1
of each year.
Premiums, copays, coinsurance, and deductibles may vary based on the level
of Extra Help you receive. Please contact the plan for further details.
This contract is renewed annually, and availability of coverage beyond the
end of the contract year is not guaranteed. This plan may not be available
to Medicare beneficiaries in the following contract year because by law, plan
sponsors, like Health Net, can choose not to renew their contract with CMS,
or they can reduce their service area, and CMS may also refuse to renew the
contract, thus resulting in a termination or non-renewal.
Individuals must have both Part A and Part B to enroll. Medicare beneficiaries
can only enroll in these plans during certain times of the year and must
continue to pay their Medicare Part B premiums. Plan benefits and cost-
sharing may vary by plan, county and region. Contact Health Net for more
information.
You must use plan providers except in emergency or urgent care situations. If
you obtain routine care from out-of-network providers, neither Medicare nor
Health Net will be responsible for the costs.
This information is available for free in other languages. Please contact
our customer service number at 1-800-275-4737 (TTY/TDD users call
1-800-929-9955), 8:00 a.m. to 8:00 p.m., 7 days a week.
Esta información está disponible en forma gratuita en otros idiomas.
Comuníquese con el número de nuestro servicio al cliente al 1-800 275-4737.
Los usuarios de TTY/TDD deben llamar al 1-800-929-9955. El horario de
atención es de 8:00 a.m. a 8:00 p.m., los siete días de la semana.

CA96688 (9/12)
Health Net of California, Inc. is a subsidiary of Health Net, Inc. Health Net
and Health Net Seniority Plus are registered service marks of Health Net, Inc.
All rights reserved.